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Finding the right nursing home, step by step

1. Figure out whether a nursing home is needed

If you can draw on good local resources, the best choice for now might not even be a nursing home.

No one looks forward to moving into a nursing home or putting a loved one there. But what to do when Dad is losing an alarming amount of weight because he lives alone and doesn't eat well, or when Mom's deepening depression and forgetfulness make her neglectful of vital medications? A nursing home may truly be the best option.

You may be able to push back the day of reckoning for months or years. There is likely more support in your community than you suspect. Tap the local Meals on Wheels program to help your father stay well nourished, for instance, or adult day care to take the edge off your mother's depression by connecting her with other people. However, a frail elderly person who may have already fallen and broken a hip or who has been wandering the neighborhood because of progressing dementia must have full-time care.

We have created a four-step tool that first will help you determine whether nursing home care can be put off, at least for a while. Then, if you conclude that a move can no longer be delayed, we will help you find a home that best meets your loved one's needs — human as well as physical and medical. Finally, we will provide tips on how to stand watch so that he or she continues to receive skilled and compassionate care as time passes.

Arrange an evaluation. Your loved one should have a thorough geriatric assessment to evaluate his or her physical and mental status. A geriatrician, or a doctor or nurse practitioner with geriatric training, would be ideal, but such specialists can be challenging to find in some areas. Your mom or dad's primary care physician is another option; phone ahead for reassurance that they can do a thorough assessment. The most important element will be your loved one's degree of ability to conduct "activities of daily living" — sufficient upper-body strength to get out of a chair unassisted, adequate dexterity to bring fork to mouth, and enough range of motion to pull on pants or a sweater, for example. Balance will be checked to assess the risk of falls. Memory deficits, signs of depression or anxiety, and indications of dementia and Alzheimer's will be evaluated. Simply identifying all the issues can take a big weight off a worried family's shoulders. "When you frame it by what they need, then you can start putting together a plan," says Cheryl Phillips, chief medical officer and geriatrician for California-based On Lok Inc., which provides long-term care and services for the elderly. If your loved one doesn’t have a doctor or the means to get to one, the local Area Agency on Aging may be able to come to the house or to do an initial, if less thorough, assessment over the phone.

Add your own insights. Input from family members should be integrated into the evaluation. The particulars of day-to-day concerns — trouble persuading Mom to take a shower, or her habit of forgetting to turn off the stove — will help guide the assessment, inform the plan of care, and narrow the choices that will have to be made.

Look to your community for help. "If they don't need 24-hour care, many people could avoid a nursing home for one or two years," says Susan Reinhard, AARP senior vice president for public policy. The Area Agency on Aging will have a list of local services, from volunteer groups that arrange rides for older folks to get to doctors' appointments to the businesses that provide in-home nursing care and assisted-living facilities. The Eldercare Locator Web page, maintained by the federal government, is a good resource to use as a starting point. You can search for help by ZIP code.

Consider hiring a professional. Barbara Gortych, a Boston psychologist, recruited a geriatric care manager in Florida near her mother, to help find local resources and assist in care decisions. When Gortych was unable to visit, care manager Stephanie Swerdlow kept her informed about her mother's status and services that were needed. Over the years, she helped Gortych arrange for occasional companion care to help her mother shop for groceries; she helped find a much-loved aide who was with her mother daily, an assisted-living facility as dementia set in and, finally, a nursing home when 24-hour care was required. It was Swerdlow, in fact, who alerted Gortych that her mother needed the range of care that only a nursing home could provide. As her mother's mind faltered and her health declined, Swerdlow would make unannounced visits to the nursing home to check on her care. "If something wasn't right, she was the one who had the rapport," says Gortych. She credits Swerdlow with bringing her peace of mind as well as local knowledge.

A geriatric care manager can be particularly helpful when you live far away but also can benefit anyone at a loss for good services for an aging loved one. You can search for one by ZIP code on the National Association of Professional Geriatric Care Managers Web site. Many clients arrange for an initial consultation to help determine the kind and level of care required and plug the family into local options, says Phyllis Brostoff, the group's president, and then call on them as needed. A consultation typically costs several hundred dollars; as-needed help generally costs from $80 to $200 per hour, depending on prevailing rates in the area.

2. How to pick the best nursing home candidates

Distance matters, of course. Our rankings will help out by flagging top-performing nursing homes.

With more than 15,000 nursing homes in the United States, even a modest-size city is likely to have 20 or more within a short drive. How can a manageable list be sifted out of so many possibilities?

The guiding principle is to balance practical considerations, such as distance and expense, with issues of quality, such as results of health and fire safety inspections. You can readily obtain quality-related information by mining such resources as the new U.S. News America's Best Nursing Homes rankings, which rely on information collected and analyzed by the federal Centers for Medicare and Medicaid Service (CMS) and data many states post online. And while you might find the thought of wading through data wholly unappealing, the numbers do have power. Not only can they help you whittle down the nursing home universe to a short list of prospects, they can also provide fodder for the types of questions to ask nursing home administrators when visiting the final candidates.

Make distance a priority. The best prescription for fending off depression and feelings of isolation in nursing home residents is to make sure they frequently see the significant people in their lives — adult children, of course, but also a neighbor dropping in for a meal or a grandchild coming to show off a good report card. Distance matters. "[A] facility that is a five-minute drive away may be best," says Phyllis Brostoff, president of the National Association of Professional Geriatric Caregivers, even if its marks are comparatively lower than those of another home an hour away. Close proximity also makes it easier to keep tabs on the quality of care a loved one is getting.

Work from the top down. Charlene Harrington, professor at the University of California, San Francisco, and an expert in long-term care, suggests searching for places rated by the federal government at four or five stars overall and eliminating lower-starred facilities. "You might end up having to keep the threes in there, but start with the top," she says. Consumer advocates are especially leery of a category of nursing homes labeled Special Focus Facilities by the government. Because of their history of poor performance, the 135 homes on the SFF list get twice the scrutiny that even one-star homes receive, as described in a separate feature. But higher-ranking homes, she warns, are more likely to have a waiting list and may take only private payers. And while the star ratings are a good place to start, they cannot capture all of life's aggravating realities — such as having limited choices if you live in a thinly populated part of the country.

Count the nurses. The number of nurses and nurse aides are one of the best indicators of good care. An ample supply means they have the time to help your mother out of bed and into her slacks or nudge her to engage with peers. It means her array of blood pressure and pain medications is closely tracked and she is monitored for side effects, drug interactions, and overmedication. You can easily compare staffing at different homes because those that take Medicare or Medicaid residents must provide CMS with nurse staffing data, which is converted into the amount of nursing time per resident.

But the numbers should be used only as a rough guide: They reflect the average number of nurses and nurse assistants in the two-week period before the most recent health inspection survey. While the surveys are unannounced — and alerting a nursing home to the date of a coming inspection is a federal crime — administrators know the surveys are conducted at least every 15 months. If it's been 10 or 11 months since the last one, homes may staff up a bit more heavily in anticipation. Staffing information also is unaudited and its accuracy is suspect. Use the reported numbers to shape your short list, says Harrington, but draw conclusions only after visiting.

Good turnover data, if they were available, would be a much better indicator of the quality of staffing. It is not unusual for a home to have annual nursing turnover of 50 or 100 percent or even higher. Because of low pay and demanding physical requirements, turnover is especially high among aides, who have the most frequent direct contact with residents. The payroll data that would allow calculating turnover are not now collected. CMS plans to begin requiring homes to submit the information, but that could be a year or more away. It is a topic very much worth raising when you visit. Step 3 will give you turnover rates to compare with the answers you get.

Buddy up to an advocate. Every state has a long-term care ombudsman whose responsibilities include pursuing complaints made about a specific nursing home, usually by a resident's family member or friend. The ombudsman is likely to know whether a facility has improved or has recently attracted a slew of complaints and should be willing to share these insights. You should also get his or her reaction to a nursing home's star ratings in the Best Nursing Home rankings for overall quality, health inspections, staffing, and medical measures. "Ask if they think the ratings are accurate," suggests Janet Wells, director of public policy at the National Citizens’ Coalition for Nursing Home Reform. Advocacy groups such as hers are another information source worth tapping — and the local ones may be more ready to dish about especially good or bad nursing homes, she says. The National Citizens’ Coalition for Nursing Home Reform lists contact information for all state ombudsmen and advocacy groups.

Ombudsmen and advocacy organizations should also be able to clue you in to disturbing events, such as an outbreak of C. difficile or MRSA infections, which are common in hospitals and nursing homes. And they can discuss a particular state's nursing home regulations, which can be more stringent than federal standards, as well as details of citations for any violations. If a nursing home is implicated in a resident's death in California, for example, the state ombudsman's office can disclose the violation. Publicly available federal data might not reflect the specifics of the incident. "It might say there was a [citation that put residents in] jeopardy, but it might not be in there at all," says Toby Edelman of the Washington, D.C.-based Center for Medicare Advocacy. Some state watchdogs are better than others, she adds. And the quality and level of knowledge varies widely: An ombudsman may be a part-time volunteer, for example, or might not be a particularly dogged advocate for nursing home residents.  

Exploit state information. Some states have their own nursing home quality measures and post the results online. The trick is finding the information. It may be hosted by the department of public health or buried in nursing home "licensing and certification" sections. Dig around on the state's home page, their department of public health page, and anything you can find on nursing homes or certification and licensing. Terms to guide your clicking: violations, deficiencies, state surveys, inspections and 2567 forms.

The details can be telling. While some states simply rehash the federal information, others unveil specific results from the previous health and fire inspection as reported by the surveyors on federal form 2567, which describes investigations that earned violations for the facility — staff neglect that contributed to a resident's injury from a fall, for instance, or a resident's violent agitation because nurses failed to follow medication instructions. The Illinois Department of Public Health Web site, for example, posts some 2567 forms online with their nursing homes. They also have a roundup section that lists, by quarter, the fines slapped on specific nursing homes, though not the details of the violations that garnered them. The California Department of Public Health Web site has a separate page that allows users to identify homes the state found responsible in the death of a resident and to read the 2567 forms to see what happened.

Broader nursing home information is not limited to federal or state Web sites. For example, the California Health Care Foundation Web site, which Harrington helped create, lists helpful information such as the percentages of residents at a home who require certain kinds of special care because of, say, reduced physical function or impaired cognition, compared to the state nursing home average. That will give you an advance sense of a home's ability to provide a service that your loved one may need. Hourly nursing staff wages and rates of staff turnover, with comparisons to regional averages, also are available.

3. The visit: How to size up a nursing home

Ask the right questions, know the signs of good and bad care, use your senses. It's detective work.

Once you've whittled down the universe of nursing homes to a few possibilities, it's time you visit. No matter how diligent your research, data are only part of the story, and glossy brochures are an unknown mix of facts and marketing. "A lot of facilities say they offer Alzheimer's care, but it doesn't necessarily mean they have [the correct staffing and] skills to do so." says Cheryl Phillips, chief medical officer and geriatrician for California-based On Lok Inc., which provides long-term care and services for the elderly.

You'll need to plan your tour in advance. Bring the U.S. News checklist to jog your memory. And be ready to use all of your senses, from sight to smell, to build a profile of each home. If time allows, visit more than once, ideally at different times of day and on different days of the week. On Saturdays and Sundays, for example, nursing homes may operate with lighter staff, which could compromise residents' care. Mealtimes can be particularly revealing — the routine, the quality of the food, and the attention paid to residents who require help eating. As you look around, keep the following points in mind.

Fancy wallpaper is nice, but… Institutional white walls are hardly inspiring, and a drab environment can sour the soul in people already prone to depression. It's natural to equate a sunlit lobby and tasteful decor with high quality. But there are better ways to gauge a home's overall vibe. Look for a full parking lot when you arrive, says Susan Reinhard, senior vice president for public policy at AARP and a former professor of nursing. Throngs of visitors tell you families and friends are welcome. Do you hear the chatter of grandchildren? Laughter? Music? The nursing home Barbara Gortych chose for her mother "may not have been the fanciest, but the quality of care I liked very much." She recalls observing the facility before moving her mother in and finding the staff plentiful, efficient, and tender. And her impressions remained consistent; "My mother could give you a run for your money," she explains. "They never seemed to lose their sense of humor."

Do you smell urine? It not only is unpleasant, but it suggests understaffing and goes beyond keeping residents dry and comfortable. Incontinence is a major reason for moving someone to a nursing home, and urine-soaked pants or bedding can break down elderly skin. And while some residents may need a urinary catheter because of a temporary or continuing medical condition, catheterization should never be used to manage incontinence, says Phillips. Long-term use invites urinary tract infections that can be deadly in individuals whose health is already compromised. Helping residents get on a regular bathroom schedule — which requires adequate and efficient staffing — is a primary tool for managing incontinence. Pay a visit in the morning to see how the staff handles residents who are just waking up and may have not been to the bathroom all night. No urine odor but a strong antiseptic smell? It might be an attempt to cover poorly monitored incontinence.

Quiz administrators who know the numbers. Bring along printouts or notes of Best Nursing Homes data, and ask for explanations in a friendly, nonconfrontational manner, suggests Phillips. “If they’re a five-star facility, ask how they got there,” says Janet Wells, director of public policy for the National Citizens’ Coalition for Nursing Home Reform, a Washington, D.C.-based advocacy group. If the facility is down at two or three overall stars, or performance in a particular area such as medical quality measures seems questionable, ask the administrators how they got those marks and what they've done to improve. The medical quality measures and staffing sections are based on self-reported data, so a touch of skepticism is healthy.

If you've haven't already absorbed the home's inspection reports by finding them on your state Web site (not all states post them), ask an administrator to show them to you. Also ask for previous reports. Nursing homes don't have to let you read the Form 2567 survey reports other than the most recent one, so if a home has retained them and gives you access to them, that is a good sign. Comparing several consecutive surveys could reflect a facility's progress — or a slip in care. The observations of the survey team on the 2567 forms will draw a picture far more vivid than any guided tour ever could — a pile of soiled linens in the hallway, food left on a counter for hours. "If it's thick, that's already a warning," says Wells of the survey report, which covers about 180 individual health-related requirements. The details can also inspire more pointed questions for the director of nursing or an administrator, as the facility's plan for correcting the situation is also on the 2567 form. And if the home's managers are too busy to help you understand the details — even by appointment — that tells you something about the staffing level or openness. Or both.

Ask about the violations described on the 2567 form. If an inspection report states that nurses didn’t wash their hands as they went from one resident to another, ask why not and what has been done to address the findings. Infections are doubly worrisome in nursing homes: The elderly are more susceptible to disease, and the close quarters — and shared, hands-on care from nurses and aides — make for efficient transmission. Other red flags, says Wells, include untreated weight loss, which can lead to significant frailty; medication errors; untreated pressure sores, which can be painful and can send a resident along a bedbound trajectory; and use of physical restraints. While declining in popularity, "safety belts" that strap a resident into a wheelchair or bed, says Wells, may actually trigger harm if a person already prone to poor balance tries to get free and falls in the process.

As picky and obsessive as inspection findings may read, they often don't go far enough. A 2008 report by the Government Accountability Office concluded that the state surveyors frequently miss or understate the extent of serious care problems. Between 2002 and 2007, federal surveyors did follow-up inspections of nursing homes recently evaluated by their states. They found that 15 percent of the state surveyors had overlooked at least one problem carrying a risk of death or serious injury, such as untreated pressure sores or weight loss.

Discuss staffing with administrators. The National Citizens’ Coalition for Nursing Home Reform, which has a helpful explanation of the ways in which nursing homes are measured, suggests a ratio of at least 1 registered nurse, licensed practical nurse or certified vocational nurse, plus 1 certified nurse assistant for every 5 residents during the day, every 10 residents during the evening, and every 15 residents at night. A home's director of nursing should be able to give you these numbers, and the Best Nursing Homes page displays ratios of nurses to patients, although they are not broken down by time of day.

High staff turnover is a special challenge for nursing homes. "Three out of four staff leave every year," says Charlene Harrington, professor at the University of California, San Francisco, and an expert in long-term care. "That's a new staff person about every three months." Studies show that high turnover rates lead to generally poorer care. One study suggests that families should look for a turnover rate below 30 percent for registered nurses, below 50 percent for licensed practical nurses, and below 40 percent for nurse assistants. Until CMS begins providing turnover data, all you can do is ask a home for its  turnover rates. You could also chat up some of the nurses and aides about how often employees seem to come and go.

Even if turnover is low, scheduling can hamper care. "Does the facility tend to have the same caregivers day after day, or do they randomly assign ... or rotate staff?" asks Phillips. The more consistent the contact between your mother and her nurses and aides, the better they will understand her needs and be her intelligent advocates.

As part of selecting trustworthy staff, nursing homes are required to run a state background check before a hire, but some facilities are broadening their due diligence by also conducting a national background check. The more thorough, the better.

Not all nurses are the same. Some homes make frequent use of temporary or "agency" nurses; others do so only occasionally, and still others have a policy against using them at all. Ask. "If they're doing it regularly," says Wells, "it probably means they're desperately understaffed."

A first impression of an abundant nursing staff may be misleading. Some may be private duty nurses hired by families to supplement the care provided by the home. Ask an administrator or nursing director.

Tailor your questions to your loved one's needs. No one facility is best for everyone. Your 85-year-old father needs a shorter stay but a higher level and intensity of nursing if he is being discharged from a hospital after a bout of pneumonia than if he needs management of a chronic condition like diabetes or heart failure. If your mom recently had a stroke, ask about stroke rehabilitation and how she will be kept safe and mentally engaged. Don't settle for "we have lots of residents who’ve had a stroke and plenty of services for them." You want specifics, says Reinhard of AARP. First, find out from your mother's doctor how many rehab hours of stroke care are needed, say, of speech and occupational therapy. Using this as a baseline, you'll want the nursing home administrators to prove they've got a robust staff appropriately trained to provide the therapy your mom needs, she explains, not that their therapists come in for a few hours a week and serve a long list of residents.

A history of falls often leads families to consider a nursing home. If that is one of your concerns, ask how falls are prevented. "Do they just use lap belts?" says Phillips, who also specializes in geriatric medicine. Or, because nighttime trips to the john are a frequent cause of falls, "do they have exercise and balance programs, and creative ideas like [foot placement] maps on the floor" leading from the bed to the bathroom? A night light next to the bed may be helpful, she explains, or the family may need to goad staff to be proactive, checking on your mother every few hours at night to ask gently if she needs help going to the bathroom.

Observe — and talk to — the staff. Your loved one will spend more time with nurses and aides than with anyone else, so watch how they relate with residents and one another. When Michelle Becker visited a nursing home on the shortlist of possibilities for her grandmother, she saw a resident in a wheelchair laughing and joking with a nurse seated nearby. Becker, a registered nurse who works for an elder services company in Milwaukee but spent a few short stints working in nursing homes, wondered whether duties somewhere else were being shirked. She and her family ultimately chose that home, deciding that what counted was the evident caring and connectedness that Becker had observed. On a tour of a different nursing home, Becker was turned off when she saw call lights blinking outside several rooms, only to see the same lights still blinking when she swung back later. It suggested inefficiency, short-staffing, or plain lack of caring.

How staff members interact with each other is another tip-off. At yet another nursing home Becker visited, she was repelled by gossipy chitchat she overheard at a nursing station. "They were talking about how 'So-and-so didn't show up for work this morning — they were probably out partying,' " says Becker. And the cluster around the station made her wonder, again, whether residents' needs were being neglected. Becker hardly felt comfortable at the idea of her grandmother in the care of such staffers.

At some point during a visit, go right to the source. Ask several nurses and aides how many residents they have to care for on a daily basis and how heavy they feel their workload is. Harrington has seen the threshold at some facilities reach 12 or 15 residents per staff member: "That is really not enough."

Watch how they eat. Malnourishment is often a very real concern for elderly people and nursing homes alike. To gauge a home's commitment, visit at least once during mealtime. "Some homes give hardly any help," says Harrington. Enough aides should be available to help all residents who have trouble feeding themselves. "It takes at least 30 minutes," she explains, to help such a person eat safely and have enough time to chew slowly without choking. Keep an eye out for untouched trays being picked up from the cafeteria tables or from residents' rooms — a possible signal that staff isn't giving those folks the assistance they need. Fresh water should also be readily available in all parts of a home because dehydration plays into the challenge of keeping residents properly nourished. Sparking residents' appetite, too, must be taken seriously as they often take medications that can blunt their interest in eating. Phillips recalls how one nursing home piqued residents' urge: As the time neared, a bread maker would be plugged in at the nurse's station, and "the aroma of baking bread would stimulate their appetites."

See how they play. No matter what age, everyone needs recreation and playful stimulation. Walk into a nursing home and see wheelchairbound residents parked in a semicircle around the television? "That's kind of a bad sign," says Harrington. Checking the activity schedule or, better yet, speaking with an activities director, will give you a feel for the facility's level of creativity — even if funds are tight — and its commitment to residents' emotional and cognitive health. Excursions should be expected, says Harrington, to the local art museum, a park, or a ballgame. And because volunteer groups are typically just a few phone calls away, Harrington says a facility should be able to recruit outside help, say, someone to come in and teach an art class, kids from a nearby school to do skits, or amateur musicians to perform. Special events — like a barbecue to which families are invited or holiday-themed parties — should be regular occurrences.

Talk to residents and their families. These people will have some of the best insights about the level of care at a given nursing home. But a generic question like, "Are you happy here?" will get you a generic response. It's wise to tactfully inquire about the things that matter most to your loved one. If incontinence is a primary reason you're considering moving your mother into a nursing home, ask residents if they get timely help to make it to the bathroom. Wells suggests also posing similar questions to family members: "If your parent needs to go to the bathroom, do they get help? Have you ever visited to find your mother sitting in her own waste?" If your concern about your dad is that he's not particularly mobile, tailor the inquiry, says Wells: "If they have a pressure sore and need to get repositioned, does it happen?" Be sure to ask if the residents have the same nurses and aides caring for them most of the time. Being on the receiving end of a rotating staff schedule is unsettling, and the nurses and aides won't get to know your loved one's specific medical needs and personality quirks. Many facilities have resident or family councils that may be able to offer advice and comfort.

4. Following up: Making sure you picked the right nursing home

You can't stop paying attention after a loved one has moved in. Vigilance is the price of good care.

You hope and pray the chosen nursing home is a good one. But the hard truth is that the first few weeks are bound to be difficult. And getting through them without trauma is no guarantee that the months and years ahead will be uneventful. You'll need to keep all of your powers of observation and diplomacy intact in order to monitor your loved one's care and be sure it remains as skilled and compassionate as possible. Here is time-tested advice from experts:

Expect an adjustment period. Moving someone you care for into a nursing home will be tense and painful. "It was the worst day of my life because it was the beginning of the end," Barbara Gortych says of moving her mother from assisted living into a nursing home in Florida. At every turn, she says, she asked herself: "Am I doing the right thing?" It is simply inevitable that family members as well as the newly admitted resident will experience some difficulty in the transition. Still, says Cheryl Phillips, chief medical officer and geriatrician for California-based On Lok Inc., a provider of long-term care and services for the elderly: "If after the first month or so your mom still seems absolutely miserable, it may be time to talk [and ask yourself], 'Do we need to look for a different facility?' "

During the first few weeks, watch for dramatic changes in the health, disposition or appearance of your loved one. While illness and accidents are facts of life in a nursing home, says Janet Wells, director of public policy for the advocacy group National Citizens’ Coalition for Nursing Home Reform, "someone who is relatively active shouldn't experience a steep decline." A rapid change may be because of inadequate care or neglect or abuse. Is your mother losing weight? She may have an undetected medical condition, or she may not be getting enough calories. Malnutrition is a significant concern in nursing homes. Tremors can hamper the ability to feed one's self and medications can cause appetite loss — or worse.

Broaden your focus over the long term. If your sharp and active mom becomes dull and lethargic, suspect drugs. An ongoing concern in nursing homes, says Wells, is "the use of medications to keep people quiet so they're not a bother and don't require staff." Besides lessening mental acuity, anything that discourages residents from getting out of bed and being active can instigate pressure sores and muscle atrophy, she says. She points to January's news that pharmaceutical company Eli Lily & Co. agreed to a $1.42 billion settlement with the federal government for marketing Zyprexa, an antipsychotic, as a drug for dementia. Zyprexa is not approved for such use. In addition, says Wells, it is one of the drugs that nursing homes sometimes give patients without dementia to make them easier to manage.

Check for special skills. You want the staff not only to be alert for health changes but to be able to manage them before they become major concerns. If your mother develops a painful bedsore, or pressure ulcer, is she treated by staff members specially trained in wound care? The federal Centers for Disease Control and Prevention reported in February that only 33 to 40 percent of nursing home residents with significant pressure ulcers received such care in 2004.

Be firm, but don't yell. Feeling guilty about having to admit a loved one to a nursing home or distraught and helpless as a family member's health declines, some families take out their emotions on nurses and aides — the very people charged with the resident's care. During her decades in the industry, Phillips, the California-based chief medical officer, has watched families explode at staff, shouting and making finger-wagging threats to sue. Bluster and anger never work, she says; "care for your loved one never becomes any better" because of such outbursts. The goal is to have these essential caregivers advocating on your dad's behalf — especially when you're not around.

One demand worth pressing, however, is that the same people care for your father regularly so that he gets to know them and vice versa. "A lot of nursing homes don't do that," says long-term care expert Charlene professor of the University of California, San Francisco, because staff schedules traditionally rotate. "[You may have to] argue with the nursing director to get a consistent staff assignment," she says, but "I think facilities will respond if families ask."

Win over the staff. Identify your dad's most consistent caregivers and ask them how you can make their jobs easier, Phillips suggests. Such efforts will reflect your respect for the people responsible for meeting the most basic and intimate daily needs of those unable to cope on their own. Get involved yourself if you can. Lighten an aide's load by coming at mealtimes to help your dad eat if he needs assistance, or take him outside to walk the grounds. Employees at the nursing home should respond. "I think the people who get the best care have somebody going as often as possible," says Harrington.

Share your inside knowledge. You can connect with staff by conveying information about personality quirks, special interests, or medical highlights. A father's history of depression or anxiety should prompt the question, "What were the things [done] at home that worked?" says Phillips. If classical music or e-mailing the grandkids lessened his symptoms, pass that along — and then bring in or mail the nursing home his favorite Bach and Mozart CDs, or arrange for a laptop so he can e-mail.

Ask staff about specific problems. Phillips cites one resident with dementia who became highly agitated when staff tried to get her to take a shower in the mornings. When her adult daughter found out, she explained that her mother's parents had been killed in a death camp during the Holocaust. "Strangers taking her to the shower had a very different meaning for her," says Phillips. So the routine was altered: The daughter brought her mother's bathrobe — a familiar, safe reminder of a bathroom routine — and was present several times when her mother showered; the schedule was moved from the morning to later in the day so her mother wasn't groggy and disoriented from just having awakened; and the same aide provided assistance, to avoid an unfamiliar face.

Be alert for nursing home shifts. Changes, not necessarily positive, can come suddenly and from unexpected directions. When her mother's small nursing home was sold to a large chain, says Janet Wells, "the quality of care went way down." Regularly chatting with staff and participating on the home's family council might help you catch wind of potential changes before they happen.

To see U.S. News' America's Best Nursing Homes rankings, go to .

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